Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avalon By Otterbein At Perrysburg during CMS and state inspections, most recent first.
The facility failed to monitor the medication refrigerator temperature consistently to support proper medication storage. Review of temperature logs showed multiple days across several months with no documented checks, and the ADON confirmed the refrigerator should have been monitored daily. The ADON also stated the refrigerator could contain medications for any resident, and the facility policy required refrigerated medications to be stored at 36 to 46 degrees Fahrenheit.
A facility failed to ensure long-acting insulin was given as ordered for four residents with diabetes. MARs showed repeated missed doses of Lantus/Insulin Glargine because staff documented blood sugar was “outside of parameters,” even though the physician orders did not include any hold parameters. The DON confirmed the insulin had been withheld and that it should have been administered as prescribed.
Improper Food Storage and Unsanitary Kitchen Conditions: Surveyors observed unsanitary conditions and improper food storage in multiple kitchen areas, including a freezer with food and dust buildup, an opened condiment stored on a dry shelf, cleaning wipes stored next to food items, a dented can in line for use, open unsealed cookie packages, and a broken bottle of coffee creamer with dried residue on the outside. Staff confirmed the findings, and the facility policy required food to be stored, labeled, and dated to support stock rotation and prevent food illnesses.
A resident with Alzheimer’s disease, HTN, OSA, HLD, and HF had a DNRCC physician order in the chart, but there was no physician-signed DNRCC advance directive and the care plan listed the resident as full code. The ADON confirmed the conflicting documentation and was unable to determine the resident’s correct code status.
Failure to Maintain Room Repairs: Two residents had room conditions that were not maintained in good repair. One resident’s bathroom door was split at the hinges, and the entry wall had a hole, scrape, and exposed drywall. Another resident’s room had large gouges with exposed drywall behind the bed. On repeat observation, both rooms remained in the same condition, and the MD verified the repairs were needed.
Failure to provide transfer and discharge notifications for two residents. One resident with an open wound, anxiety, heart disease, and hernia was sent to the hospital for rectal prolapse, but the record lacked evidence of a transfer/discharge summary, notice to the resident or family representative, or Ombudsman notification. Another resident with HTN, Afib, COPD, chronic respiratory failure, and a history of COVID-19 was transferred to an acute care facility, but there was no evidence of report to the receiving facility or Ombudsman notification.
Failure to include dental needs in the care plan. A resident with multiple chronic conditions and moderate cognitive impairment had ongoing dental problems, including tooth extractions and follow-up dental care, but the care plan addressed several other needs and did not include any dental supports or interventions. The resident reported her teeth had been bad for a long time and were again bothering her, with trouble eating; an LPN and the DON confirmed the dental concerns and the lack of care plan coverage.
Failure to Provide Translation Assistance for a Spanish-Speaking Resident: A resident who only spoke Spanish had a care plan intervention to provide a translator, but no translation equipment or communication boards were observed in the room. Family members said they often translated when present, but were not always available, and staff confirmed the facility did not provide translation services or communication devices. During wound and incontinence care, staff spoke English and the resident did not respond to questions.
An LPN administered insulin glargine and insulin aspart to a resident and then removed the pen needles and placed two used needles in the resident’s bathroom trash can. The LPN confirmed the disposal method, and the ADON verified that insulin pen needles should be placed immediately into a sharps container per facility policy.
Failure to address nutritional needs after readmission: A resident with parkinsonism, myasthenia gravis, dysphagia, and cognitive impairment was noted to be underweight and previously on a weight gain program with supplements, but diet and supplement orders were discontinued after return from the hospital and were not reordered for 15 days. The RD did not assess the resident on readmission, and the record showed a significant weight drop in one month, while staff reported decreased appetite and limited intake.
A facility failed to ensure active physician orders were in place for oxygen therapy and failed to ensure oxygen tubing was dated for three residents. Two residents with COPD and one resident with COPD and chronic respiratory failure were observed wearing nasal cannulas delivering oxygen, but one had no current oxygen order and all three had undated tubing. The ADON verified the missing orders and undated tubing.
Pharmacy recommendations were not addressed by the physician in a timely manner for two residents. One resident with Parkinson's disease and other chronic conditions had monthly pharmacist reviews with no documented recommendations or physician response in the chart, and another resident with parkinsonism and related disorders had midodrine-related recommendations that were not shown as reviewed or acted on by the physician, with the DON later signing them as completed.
An LPN administered insulin glargine and insulin aspart to a resident without disinfecting the rubber stoppers on the insulin pens before attaching the needles. The LPN confirmed the omission, and the ADON stated the stoppers should have been disinfected first. Manufacturer instructions for the insulin aspart pen required alcohol disinfection of the rubber stopper before needle attachment.
A resident with impaired cognition and multiple medical conditions was moved to a different room without written notification to the resident or their POA, as required by facility policy. Staff acknowledged that while verbal and text communications may have occurred, there was no documentation or written agreement regarding the room transfer.
Medication Refrigerator Temperature Monitoring Lapses
Penalty
Summary
The facility failed to ensure the medication refrigerator temperature was monitored to support safe storage of medications. Review of the medication refrigerator temperature logs for January 2025 through August 2025 showed no evidence that temperatures were monitored on 9 days in January, 13 days in February, 18 days in March, 15 days in April, 26 days in May, 14 days in June, and 26 days in July. During an interview on 08/13/25 at 8:15 A.M., the ADON confirmed there was no evidence the refrigerator temperatures were monitored on those days and stated the medication refrigerator should have been checked daily. The ADON also stated the refrigerator could contain medications for any resident in the facility. Review of the facility policy titled Medication Storage, dated 07/09/21, stated refrigerated medications would be stored at 36 to 46 degrees Fahrenheit.
Insulin Held Without Physician-Ordered Parameters
Penalty
Summary
The facility failed to ensure insulin was administered per physician orders for four residents reviewed for insulin administration. Review of the medical record, MARs, staff interviews, and the facility medication administration policy showed that long-acting insulin was repeatedly withheld and documented as not given because blood sugar was “outside of parameters,” even though the physician orders for the insulin did not include any parameters to withhold the medication. The DON confirmed during interview that the insulin had been held on the documented dates and that the orders did not contain withholding parameters. Resident #13 had diagnoses including dementia and Type I diabetes mellitus and was moderately cognitively impaired. Her record showed multiple Lantus orders over the course of the stay, including orders for daily and later twice-daily administration, with no withholding parameters. The MAR showed numerous missed bedtime doses and several missed morning doses because blood sugar was outside of parameters, and the DON stated there was no reason for the insulin to be withheld. Resident #20, Resident #8, and Resident #19 also had diabetes diagnoses and orders for long-acting insulin without withholding parameters. Their MARs showed multiple instances where Insulin Glargine or Lantus was not administered because of “outside of parameters,” including missed morning and bedtime doses. The DON verified these doses were documented as not administered for that reason and confirmed the orders did not include parameters for holding the medication. The facility policy stated medications would be administered as prescribed.
Improper Food Storage and Unsanitary Kitchen Conditions
Penalty
Summary
The facility failed to ensure foods were properly stored and that kitchens were maintained in a safe and sanitary manner for residents receiving food from the kitchens in House 1, House 2, and House 5. In House 2, surveyors observed the reach-in freezer with a frozen brown substance hanging between the shelf bars, dust buildup along the bottom grating, and debris and food buildup in the bottom. A partially used bottle of Worcestershire sauce that was opened on 05/21/25 and labeled to refrigerate after opening was stored on the dry storage shelf, and an open container of sanitization wipes was stored in a lower cupboard next to an open bottle of vanilla. An Admissions Staff member verified these conditions during interview. In House 1, surveyors observed a dented can of corn in line for use and open, unsealed packages of pecan cookies and fudge stripe cookies on the dry storage shelf. In House 5, surveyors observed an open, partially used 1.5 liter bottle of coffee creamer on the counter with a broken pump top and spilled, dried creamer covering most of the exterior of the bottle. A CNA verified the bottle was broken, spilled, and should have been thrown away, and then disposed of it. The facility policy titled Food Storage Policy and Procedure stated food was to be stored, labeled, and dated to assure stock rotation and prevent food illnesses.
Advance Directive and Code Status Documentation Inconsistency
Penalty
Summary
The facility failed to ensure advance directives were clearly and accurately documented in the medical record for one resident (#22) reviewed for code status. Resident #22 was admitted with diagnoses including Alzheimer’s disease, hypertension, obstructive sleep apnea, hyperlipidemia, and heart failure. The current physician orders showed a DNRCC code status, but the medical record contained no evidence of a physician-signed DNRCC advance directive. In addition, the care plan identified the resident as full code. During interview, the ADON confirmed the resident had a physician order for DNRCC, there was no physician-signed DNRCC advance directive, and the care plan listed full code, and stated she was unable to determine the resident’s correct code status.
Failure to Maintain Room Repairs
Penalty
Summary
The facility failed to maintain the physical environment in good repair for two residents. In Resident #9’s room, the bathroom door was observed split at the top and bottom at the hinges, and there was an approximately two-inch hole with an about two-foot-long scrape along the wall from the entry door to the bedroom area with exposed drywall. Resident #9 confirmed the bathroom door was broken and stated she was not sure how long it had been that way; she also stated the hole and scrape did not look safe and that she did not recall the wall ever not being in that condition. Resident #9’s room was observed again two days later and the bathroom door remained broken and splitting at the hinges, with the hole and exposed drywall still present along the entryway wall. In Resident #16’s room, the bed was in the low position and the wall behind the bed had large gouges with exposed drywall. Two days later, the bed remained in the low position and the wall behind it still had large gouges with exposed drywall. The Maintenance Director verified that the door in Resident #9’s room was broken at the hinges and that the wall in both residents’ rooms was in need of repair.
Failure to Provide Transfer and Discharge Notifications
Penalty
Summary
The facility failed to ensure transfer and discharge notices were provided for two residents who were transferred or discharged from the facility. For Resident #63, the closed medical record showed an admission on 04/07/25 with diagnoses including an open wound on the left hip post-surgery, anxiety, heart disease, and hernia. The resident had intact cognition and was continent of bowel and bladder on the 04/14/25 MDS assessment. A nursing progress note dated 05/13/25 documented that Resident #63 was discharged to the hospital for a rectal prolapse, but the record contained no evidence that a transfer/discharge summary was sent to the receiving facility, that the resident or family representative was notified before discharge, or that the Ombudsman was notified. For Resident #3, the record showed admission with diagnoses including hypertension, atrial fibrillation, COPD, chronic respiratory failure, and a history of COVID-19, and transfer to an acute care facility on 05/06/25. The medical record contained no evidence that report or transfer notification was given to the receiving acute care facility and no evidence that the Ombudsman was notified of the transfer. The DON verified there was no documentation of a discharge/transfer summary for Resident #63, no notification to the resident or resident representative, and no Ombudsman notification for either resident; the DON also confirmed there was no evidence report was given to the receiving acute care facility for Resident #3.
Failure to Include Dental Needs in Care Plan
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed to include dental care needs for Resident #19. The resident was admitted on 07/18/25 with diagnoses including cellulitis of the lower limbs, back pain, osteoporosis, spinal stenosis, heart failure, COPD, Type II diabetes, and glaucoma. The MDS dated 07/23/25 showed a BIMS score of 8, indicating moderate cognitive impairment. The resident required moderate assistance with toilet use, bathing, parts of dressing, and transfers, and had no mouth or facial pain, discomfort, or difficulty chewing noted at the time of the assessment. Review of the care plan revised 07/30/25 showed interventions for self-care deficit, diabetes, skin breakdown, cognition, mood, falls, nutritional risk, and swallowing problems, but no supports or interventions for dental concerns. The medical record showed the resident had ongoing dental issues, including a dentist visit recommending extraction of five teeth, subsequent extractions, and follow-up dental care with additional extractions completed. During interview, the resident stated her teeth had been bad for a long time and were bothering her again, with trouble eating. Staff interviews confirmed the resident had oral surgery and ongoing dental concerns, and the DON verified there were no care plan supports or interventions for dental care.
Failure to Provide Translation Assistance for a Spanish-Speaking Resident
Penalty
Summary
The facility failed to provide translation assistance or devices to aid communication for a resident who only spoke Spanish. Resident #67 was admitted with diagnoses including cholangitis, peripheral vascular disease, Type II diabetes, disease of the pancreas, a stage two sacral pressure ulcer, and heart failure. The resident’s baseline care plan identified communication as a focus area and listed an intervention to provide a translator, with family members identified as the translators. During observation, no translation equipment or communication boards were seen in the resident’s room while the resident was resting in bed and later while sitting in a wheelchair with a daughter present. The daughter stated that she and her brother were often in the facility and could translate, but were not always available during the day or evening, and she was unaware of any translation interventions provided by the facility when family were unavailable. A CNA stated she could communicate only at a very basic level in Spanish and verified the facility did not provide communication devices or other services. During wound and incontinence care, staff spoke English and the resident did not respond to questions, and the CNA and LPN confirmed no translation services or communication devices were provided.
Improper Disposal of Used Insulin Pen Needles
Penalty
Summary
The facility failed to ensure used needles were properly disposed of after insulin administration for Resident #27, who was observed receiving insulin glargine and insulin aspart as ordered. During medication administration, the LPN removed the needles from the insulin pens and placed two used insulin pen needles into the resident’s bathroom trash can instead of a sharps container. The LPN confirmed the disposal method during interview, and the ADON verified that insulin pen needles should be disposed of in a sharps container immediately after use. The facility policy titled, Syringe and Needle Disposal, stated that needles would be placed in a one-way puncture resistant container immediately after use.
Failure to Address Nutritional Needs After Readmission
Penalty
Summary
Provide enough food and fluids to maintain a resident's health was cited after the facility failed to ensure nutritional needs were assessed and interventions were implemented in a timely manner for a resident identified with nutritional problems. Resident #48 had diagnoses including parkinsonism, myasthenia gravis, multi-system degeneration of the autonomic nervous system, dystonia, dysphagia, and need for assistance with personal care. The resident was moderately cognitively impaired, was noted to be underweight, and had been placed on a weight gain program with three nutritional supplements daily and an eight-ounce milkshake in the afternoon. After the resident returned to the facility from the hospital, physician orders for the diet and nutritional supplements were discontinued, and a regular diet and nutritional supplements were not ordered again until 15 days after readmission. The medical record showed no evidence that the RD assessed the resident's nutritional needs after readmission. Weights in the record showed a drop from 97.4 lbs. to 88.2 lbs. in one month, and staff later stated the resident had a decreased appetite and was only eating small salads brought by her husband. The RD verified the nutritional needs were not addressed on readmission and stated the 88.2-lb. weight was likely an error.
Oxygen Therapy Without Active Orders and Undated Tubing
Penalty
Summary
The facility failed to ensure active physician orders were in place for oxygen therapy and failed to ensure oxygen tubing was dated for three residents who were observed using oxygen. Resident #1 had diagnoses of COPD and a history of COVID-19, was cognitively intact, and was assessed as receiving oxygen therapy. During observations, the resident had a nasal cannula delivering oxygen at 3 lpm, and the oxygen tubing was not dated. The Assistant Director of Nursing verified the tubing was not dated and should have been. Resident #3 had diagnoses of COPD, chronic respiratory failure with hypoxia, and a history of COVID-19, was cognitively intact, and was assessed as not receiving oxygen therapy. However, the resident was observed with a nasal cannula delivering oxygen at 4 lpm, and the tubing was not dated. Review of current physician orders showed no active order for oxygen therapy, and the ADON verified there were no active physician orders and that the tubing was not dated. Resident #10 had a diagnosis of COPD and no current physician order for oxygen therapy, yet was observed with a nasal cannula delivering oxygen at 2 lpm and tubing that was not dated. The ADON verified there were no active physician orders for oxygen administration and that the tubing was not dated. Facility policy stated medications would be administered as prescribed by persons lawfully authorized to do so.
Pharmacy Recommendations Not Addressed in a Timely Manner
Penalty
Summary
The facility failed to ensure that pharmacy recommendations from the licensed pharmacist were addressed by the physician in a timely manner for two residents reviewed for unnecessary medications. For one resident with diagnoses including Parkinson's disease, type 2 diabetes, heart disease, and brief psychotic disorder, the pharmacy monthly medication reviews dated 01/18/25, 02/08/25, and 03/09/25 showed pharmacist recommendations to the physician, but the medical record contained no evidence of what those recommendations were or that the physician reviewed and addressed them. The resident's MDS dated [DATE] indicated mildly impaired cognition, and the DON confirmed there was no documentation of the pharmacist's recommendations or the physician's response. For another resident with diagnoses including parkinsonism, myasthenia gravis, multi-system degeneration of the autonomic nervous system, dystonia, and dysphagia, the pharmacist issued recommendations on 06/18/25 regarding midodrine administration, including recording BP readings on the MAR, adding hold parameters for systolic BP greater than 130 mmHg, and not giving the medication at bedtime with the last dose no later than 6:00 P.M. The record showed no physician response to either recommendation, and progress notes from 06/18/25 through 07/29/25 contained no evidence the physician was updated or given verbal orders. The DON later confirmed the recommendations were dated as completed on 07/29/25 and signed by her, and stated she was unable to identify the timeframe for physician response.
Insulin Pen Preparation Error
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when an LPN administered insulin glargine and insulin aspart to Resident #27 without first disinfecting the rubber stoppers of the insulin pen tips. During observation, the LPN prepared both insulin pens and attached a needle to each pen before administration, and she confirmed in interview that she did not disinfect the rubber stoppers prior to attaching the needles. The ADON stated that the rubber stoppers of insulin pen tips should have been disinfected before needle attachment. Review of the manufacturer instructions for the insulin aspart pen delivery system showed that the first step in preparing the pen for administration was to disinfect the rubber stopper with alcohol before attaching the needle.
Failure to Provide Written Notification of Room Change
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident and their representative in writing prior to a room change. Record review showed that the resident, who had diagnoses including acute respiratory failure with hypoxia, heart failure, type 2 diabetes, and an amputation of the right lower leg, was admitted to the facility and had impaired cognition. There was no evidence in the medical record, including scanned documents, progress notes, or assessments, of any notification regarding the room change. The resident was unable to recall being notified about the transfer and did not know the date of the move, although she expressed comfort and no concerns with her care. Staff interviews confirmed that there was no documentation of notification to the resident or her Power of Attorney (POA) about the room change. The Social Services Designee (SSD) stated that while the POA was contacted by phone and text regarding the room change, there was no record of these communications or any written agreement from the POA. Facility policy requires written notification and documentation of room changes, but this was not followed in this instance. The deficiency was identified during a complaint investigation and affected one resident out of three reviewed for room changes.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Perrysburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Three Meadows Post Acute | 0 mi | ★★★★★ | 13 | 1 |
| Manor At Perrysburg | 0.8 mi | ★★★★★ | 29 | 0 |
| Kingston Health Center Of Perrysburg | 1.7 mi | ★★★★★ | 0 | 0 |
| St Clare Commons | 3.2 mi | ★★★★★ | 14 | 0 |
| Majestic Care Of Perrysburg | 3.6 mi | ★★★★★ | 39 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.